Who is in the centre?

Central fetal monitoring systems take digital data from individual CTG machines and project it on a screen in a central location in a maternity service – so all the current CTG recordings are visible in the one place. It SEEMS like a great idea at first look. If many people can see the CTG recording, surely no one will miss a problem. The assumption that central fetal monitoring MUST improve outcomes is so strong that even though there has never been a research study that shows better outcomes, these systems are being rolled out in maternity services around the world.

“Being K2ed”

My PhD research looked at a phenomenon that midwives at one particular hospital has started calling “being K2ed” – after the name of the central fetal monitoring system (Small et al., 2021; 2022). When the K2 Guardian central fetal monitoring system had been introduced, midwives began experiencing people (doctors and senior midwives) coming to the birth uninvited, in response to something they had seen at the central monitoring station. While this was sometimes seen as helpful, it was mostly experienced as disruptive, intrusive, and disrespectful.

The experience of “being K2ed” prompted midwives to change the way they provided care. These changes were attempts to keep unwanted intrusion from happening, rather than being aimed at improving birth outcomes, or women’s experiences of their births. They included things like using a fetal spiral electrode, getting the woman to remain on the bed in a particular position, coached pushing, and spending more time documenting rather than supporting the woman.

My research looked at what was going on in one hospital. I regularly hear from others that similar things happen in their workplaces too – but so far no other research has looked at this issue. So I was delighted when I was introduced to two midwifery researchers working in Iceland, who had also been looking at the impact of central fetal monitoring in their maternity hospital. We collaborated on writing a paper so their work would be more widely available, and I’m pleased to report that it has just been published. For a short time, you can read the full paper for free here.

Same same but different

Midwives in Iceland, with a central fetal monitoring system called Milou, described very similar experiences to the midwives I had interviewed in my research. One of the midwives, Dagmar said “I try not to let it get to me that this is going on, although I know that they are all watching, but it sill does have an effect on me if the woman starts pushing and the fetal cardiogram needs observation, I am aware that I will have someone coming into the birthing suite“. The same pressure to increase documentation and the same loss of self-confidence that I described in my research, was also happening at this hospital.

Brynja Helgadóttir (the midwife who designed the research and conducted the interviews) took an approach I hadn’t, and that led to some interesting new findings. She compared the experiences of midwives who had only ever worked in the birth suite with central fetal monitoring, with midwives who had worked in the same hospital both before and after the Milou system had been installed. Midwives who had only ever known what it was like to work with central fetal monitoring appeared to be more accepting of the intrusion, to feel they lacked confidence in the CTG interpretation skills, and to consider that remaining present all the time with the birthing woman was not needed.

As Helga and I looked at Brynja’s findings in her thesis, we could see hints that what was happening was a fundamental shift in what it mean to be a “good midwife” in this setting. While the concept of what it means to be a midwife has shifted through the history of midwifery and will continue to do so, it is important to question what is driving the change and whether it is a positive movement for midwives and the women they serve. There is the very real risk that central fetal monitoring systems shift the midwives focus from putting the woman at the centre of their care, to prioritising the provision of information to doctors outside the birth room to reduce their anxiety about what is happening in the room.

It’s time to pause and think

Central fetal monitoring systems were not designed by, or for, midwives, nor were they designed in collaboration with or for the benefit of birthing women. Like CTG monitoring itself, these systems have been introduced into clinical practice despite no evidence they make anything better, and concern they might undermine safety (Small et al., 2022). Once installed at a hospital, birthing women and midwives cannot opt out of their use. I doubt that many women are even told that their personal clinical information is visible to anyone who wanders in and out of the central monitoring area.

Rather than shrugging our shoulders and sighing “Oh well, that’s progress for you” – I urge you to push back. We need to slow down the introduction of central fetal monitoring systems so research can be done to understand the impact it is having in practice. We need time to pause and reflect on whether this is the right direction for midwives to take. For the midwifery profession to be self-governing and autonomous, midwifery leaders must challenge the introduction of new technology that has the capacity to redefine the essence of what midwifery is, without the involvement or consent of midwives.

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References

Gottfreethsdottir, H., Small, K., Helgadottir, B. P., & Gamble, J. (2025, Mar 1). Who is in the centre? A qualitative study on midwives’ experience of working with central fetal monitoring system. Women & Birth, 38(2), 101891. https://doi.org/10.1016/j.wombi.2025.101891

Small, K. A., Sidebotham, M., Gamble, J., & Fenwick, J. (2021, Jun 24). “My whole room went into chaos because of that thing in the corner”: Unintended consequences of a central fetal monitoring system. Midwifery, 102, 103074. https://doi.org/10.1016/j.midw.2021.103074

Small, K. A., Sidebotham, M., Fenwick, J., & Gamble, J. (2022, Mar). “I’m not doing what I should be doing as a midwife”: An ethnographic exploration of central fetal monitoring and perceptions of clinical safety. Women & Birth, 35(2), 193-200. https://doi.org/10.1016/j.wombi.2021.05.006